Canadian & Garfield Counties: EPSDT Improvement Project

Canadian & Garfield Counties:EPSDT Improvement Project James W. Mold, PI

Project Aim • Increase the number and quality of EPSDT visitsmade by Medicaid recipients to clinicians in Canadian and Garfield Counties

Project Description • Letter and follow-up phone call to 5 primary care practices in Canadian County who take care of Medicaid-insured children • All agreed to meet for lunch to hear about the project

Project Description – Canadian County • Intervention Dates: 4/07 – 9/07 • Measurement Dates: 4/07 and 11/07 • Intervention: • Academic detailing • Performance feedback • Practice facilitation • IT support • Case Management

Project Description – Garfield County • Intervention Dates: 7/07 – 6/08 • Measurement Dates: 10/07 and 6/08 • Intervention: • Academic detailing • Performance feedback • Practice facilitation • IT support • Case Management

Academic Detailing • Review of methods used by exemplary practices (those receiving large bonuses) • Review of rules for bonus payments • Provided with new Medicaid EPSDT forms and an alternative

Practice Facilitation • DFPM-trained facilitator worked with clinicians and staff at least weekly to implement desired changes in clinical processes. • Each practice had different needs and action plans.

Case Management • Contacted parents of children delinquent with regard to EPSDT visits, facilitated appointments • Helped practices link complex families with needed services

Performance Audits • Random sample of 25 children from each of 5 age categories (<1, 1-2, 2-5, 6-14, 15-20) or all available (if < 25) from current Medicaid enrollee lists • Medical records reviewed for a proportion of indicated EPSDT visits within the last year • For EPSDT visits found, quality was assessed in 5 areas (VSs, health history, developmental/ behavioral screen, physical exam, anticipatory guidance) (Quality measured on 0-4 scale with 1=25% and 4=100%)

Rates by Age Group Across All Practices at Baseline, 4, 6, and 12 Months – Canadian County Rates by Age Group Across All Practices at Baseline and 9 Months – Garfield County

Overall EPSDT Rates by Practice - Canadian County Overall EPSDT Rates by Practice – Garfield County

EPSDT Rates for <1 Year-Olds - Canadian County EPSDT Rates for <1 Year-Olds – Garfield County

EPSDT Rates For 1 to 2 Year-Olds - Canadian County EPSDT Rates For 1 to 2 Year-Olds - Garfield County

EPSDT Rates For 6 to 14 Year-Olds - Garfield County EPSDT Rates For 6 to 14 Year-Olds - Canadian County

Overall Quality of EPSDT Visits - Canadian County Overall Quality of EPSDT Visits - Garfield County

Vital Signs During EPSDT Visits - Canadian County Vital Signs During EPSDT Visits - Garfield County

Physical Exam During EPSDT Visits - Canadian County Physical Exam During EPSDT Visits - Garfield County

Health History During EPSDT Visits - Canadian County Health History During EPSDT Visits - Garfield County

Developmental/ Behavioral Screening During EPSDT Visits - Canadian County Developmental/ Behavioral Screening During EPSDT Visits - Garfield County

Anticipatory Guidance During EPSDT Visits - Canadian County Anticipatory Guidance During EPSDT Visits - Garfield County

Sensory Screening at EPSDT Visits - Garfield County Sensory Screening at EPSDT Visits - Canadian County

Blood Lead Testing at Appropriate EPSDT Visits - Garfield County Blood Lead Testing at Appropriate EPSDT Visits - Canadian County

Body Mass Index Calculation at EPSDT Visits - Canadian County Body Mass Index Calculation at EPSDT Visits - Garfield County

Conclusions - Canadian County • Primary care clinicians are willing and interested in receiving this kind of assistance with improving the rates and quality of their EPSDT visits. • There was significant improvement in quality of visits in all of the main categories in all 5 practices. • Quality continued to improve even after the PEAs left the practices. • Rates of BMI calculation and lead screening remain low. • Rates of visits in the youngest age group increased, but not a lot. • There was no improvement in rates of visits for older children.

Conclusions - Canadian County • QI interventions generally require a minimum of 6 months to effect measurable improvements. This initiative covered a lot of different issues. • The lag times for improvements in EPSDT visits for older children, whose visits are further apart, could be expected to be greater. • Practices face multiple challenges and have many competing priorities that hinder QI efforts. • Seasonal factors may have played some role in the variability of measurements over time.

Conclusions - Garfield County • Primary care clinicians are willing and interested in receiving this kind of assistance with improving the rates and quality of their EPSDT visits. • There was significant improvement in quality of visits in all of the main categories in all 5 practices. • Rates of BMI calculation and lead screening improved significantly, but remain low. • Rates of visits improved in all age groups. This was the result of substantial improvements made by 3 of the 5 practices.

Conclusions - Garfield County When compared to results of the same intervention in Canadian County: • The baseline rates and levels of quality were substantially lower in Garfield County for undetermined reasons. • Rates improved more in Garfield County, which may have had to do, in part, with more effective case management. (Note: If so, this probably had more to do with the clinicians’ willingness to work with the CM than to differences in the skills or personalities of the CMs.)

ASQ Rates at 9, 18, and 24 or 30 months* at Baseline, Post-Intervention, and Follow-up *Ages at which OSDH recommends developmental screening

Rates of Developmental Referralsat Baseline, Post-Intervention, and Follow-up 6 6* 4 1 2 1 1 0 0 *The drop from 10% (6 referrals) to zero is likely due to the physician’s confidence in the screening tool. Fewer referrals also mean cost savings for physician and patients!

Canadian & Garfield Counties: EPSDT Improvement Project